A pervasive fatalism

Many ill seniors succumb to medical 'ageism'

SAN FRANCISCO (CBS.MW) -- When it comes to treating the elderly with age-appropriate medical care, older Americans are becoming their own worst enemy.

Not only do many doctors dismiss seniors' aches and pains as an inevitable part of aging rather than probing deeper, as they would for younger patients, many older people and their caregivers internalize the message and fail to seek a second opinion or one from a geriatrician, health experts say.

Such fatalism -- and the assumption that everyone over 60 has the same health needs -- has a name: medical ageism. But that doesn't mean the medical community agrees on a singular definition.

Some find ageism in a widespread failure to promote preventive health measures or manage multiple chronic illnesses and the risk of falls in older patients. Others point to a scarcity of seniors in drug trials and providers' unwillingness to confront their own mortality.

"There are many doctors who don't enjoy treating elderly people," says Dr. Moira Fordyce, a geriatrics professor at Stanford University School of Medicine. "Sometimes the doctor has problems with aging. They don't like the changes they see in themselves, their parents or their significant other."

A focus on triumphing over mortality may itself breed a subconscious medical ageism, she says. "A lot of doctors regard death as a deceit, not as the normal end of life. If they can't save the patient, they just don't want to know about it."

Indeed, ignorance is a pervasive problem, says Dr. Richard W. Besdine, president of the American Geriatrics Society and director of Brown University's geriatrics program.

"Even at 70 or 80, there are interventions that will slow the progress or delay the appearance entirely of problems we thought strictly related to aging."

Financial disincentives

Another culprit is lurking in the education system. Only a few medical schools require geriatric coursework, and students tend not to pursue it when it's offered as an elective.

What's more, the diminishment of Medicare reimbursements that would compensate doctors for longer geriatric appointments is deterring many professionals from seeing the elderly, leading some to favor the seven-minute office visits of younger patients.

As a result, patients and caregivers are having trouble finding geriatricians and doctors with knowledge of geriatrics, some of whom may play down their qualifications, Besdine says.

"There are more out there who aren't advertising it simply because if they have too many frail older adults in their practice, they won't be able to survive financially. And that's kind of a disgrace."

While some health-care professionals have become more adept at identifying geriatric problems than they were a decade ago, many have a long way to go in learning how to treat them, he says.

"We have terrible medical ageism," Besdine says. "It operates one at a time at the bedside -- in the hands, usually, of people who don't know the data, don't understand the biology of aging or the enormous, still-recuperative capacity of older adults with serious illness.

"Functional loss, which we worry about all the time, is not a one-way street," he says. "There is recovery of function as well as loss of function occurring every day for older adults across the country."

What's more, the U.S. medical community doesn't emphasize prevention for older people, even though it's warranted, says Daniel Perry, executive director of the Alliance for Aging Research.

"They're much less likely to be counseled to quit smoking or take up exercise, much less likely to be tested for incipient diseases and health problems that may be developing."

Such ageism can be sinister, he says. "It's almost a self-hatred -- a denial of our future selves -- and we tend to turn against that. In health care, this bias against older people can have life-threatening consequences."

Defeating defeatism

As in other segments of the health-care system, seniors with acute-care needs will, for the most part, find relief, but a growing proportion with moderate disabilities is largely out of luck, says Dr. Diane Meier, a geriatrician at Mt. Sinai School of Medicine in New York City.

For example, a 67-year-old who needs a procedure such as a hip replacement, cardiac bypass or cataract surgery will be covered under Medicare, yet a cognitively impaired 87-year-old who needs help managing medications, grocery shopping and cooking is on her own, she says.

"When you start having functional dependence -- needing other people to get through the day -- our system abandons you," Meier says. "That is a function of inequitable access to care and a manifestation of endemic ageism in the health-care system."

Still, baby boomers, more likely than previous generations to be savvy consumers, can be expected to reject medical ageism when they see it and to demand more specialized care, Perry says.

"We should be encouraging people now to be squeaky wheels because that's what works in a health-care system that's increasingly constrained in what it can do," he says. "It's a system that's done less for older patients than younger ones. It's born out of fatalism: 'These people are old, sick, and they're going to die anyway.' "

How to identify medical ageism

The first step in fighting medical ageism is spotting it. Here are a few indications that your provider is dismissing your health complaints based on your age:

The doctor tells you, "What do you expect of someone 72, 82, 92?" Medical professionals should know to go beyond a pat diagnosis attributed to age, even where health problems are age-related, says Dr. Steven L. Phillips, a geriatrician in Reno. "It's not fair to anyone to write the problem off or define the problem as just age. There has to be something underlying it."

The doctor seems to lump all elderly people into the same medical category without understanding frailty. There are big differences between the so-called young elderly and the oldest old, says Dr. Iris Boettcher, a geriatrician for Spectrum Health System in Grand Rapids, Mich. She subdivides her patients into categories she labels frisky, fragile and frail. "We don't treat an infant or toddler as we do a young adult. Why wouldn't we start to distinguish at the end of the lifespan the same way we do at the beginning?"

The doctor seems to make value judgments as to the patient's quality of life. A year of life to an 80-year-old may be even more precious to him than the same year to a 40-year-old, regardless of disability, and the implications are particularly acute for diagnosing depression in the elderly, Besdine says. "With older people, the assumption can be 'If I were 75 and wrinkled and couldn't do the 100-yard dash in less than 15 seconds, I'd be depressed, too.' That's an inappropriate assessment of emotional state."

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